Autonomy

Self Determination
Motivation
Autonomy
Relatedness
Competence
Autonomy-Supportive
Medical Education:
Let the Force Be Within You!
Laura P. Shone, DrPH, MSW
Associate Professor of Pediatrics
University of Rochester Medical Center
Rochester NY
On behalf of:
Baldwin CD, Shone LP, Harris JP, Craig M, Cellini M, Varade W. Development
of a novel curriculum to enhance the autonomy and motivation of residents
• Self-DeterminationTheory: An Approach to Human Motivation and Personality,
http://www.psych.rochester.edu/SDT/index.php
• Baldwin CD, Shone LP, Harris JP, Craig M, Cellini M, Varade W. Development of a novel curriculum to
enhance the autonomy and motivation of residents. Pediatrics. 2011; 128: 633-636.
1

Self-Determination Theory: Satisfaction
of three innate psychological needs
drives motivation
Autonomy:
‣Desire to be the
source of one’s
own behavior
‣ Feeling of freedom
to choose one’s
own goals
Self-
Determination
Competence:
‣ Desire to feel
effective in
actions one
pursues and
performs
‣ Perception of
confidence and
accomplishment
Relatedness:
‣ Desire to feel connected with others
‣ Sense of belonging to a valued group
Ryan, RM and Deci, EL. Self-Determination theory and the facilitation of intrinsic motivation, social
development, and well-being. American Psychologist, 2000, 55(1): 68-78.
2

Self-determination is a key factor in
motivation, which fuels the drive to learn
Motivation = human energy directed toward a goal:
It is autonomous when the goal is chosen because
of its intrinsic value to the individual
It is controlled if the goal is dictated by others
Many forces influence a student’s motivation to learn:
‣Personal interests and needs
‣Influence of peers
‣Evaluation: grades, exams
‣System mandates: schedules, regulations,
curriculum requirements, documentation
In medical education, autonomous motivation
is constantly challenged by external controls
Internal
locus of
control
External
locus of
control
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Findings of motivation research show
these educational associations:
• Skill in rote
memorization and
algorithmic performance
• Behavior dependent on
contingencies
• Erosion of intrinsic
motivation for future
learning
Autonomous motivation
creates learners with:
• Higher academic achievement
• Higher perceived competence
• Preference for optimal challenge
• Higher self-worth
• Stronger sense of community
• More creativity
Our task: To stimulate intrinsic motivation in
learners, even though we teach in a highly
controlling environment!
Ten Cate, Kusurkar, Williams. How self-determination theory can assist our understanding of the teaching
4
and learning processes in medical education. AMEE guide No. 59. Med Teach. 2011;33:961-73.

Motivation
Self Determination
Autonomy Competence
Relatedness
How can you practice
autonomy-supportive
education?
• Give learners choices
• Acknowledge their perspectives
• Encourage their acceptance of personal responsibility
• Provide them with constructive feedback
• Evaluate them using individualized assessment
• Grant them full responsibility for specific tasks once they
have demonstrated competence
Self-determined learners thrive when they feel
autonomous, competent and part of a community
Kusurkar, Croisel, ten Cate. Twelve tips to simulate intrinsic motivation in students through autonomysupportive
classroom teaching derived from Self-Determination Theory. Med Teach. 2011; 33:978-982.
5

And what about all those rules and mandates?
• In SDT, self-regulation (like motivation) can be controlled, or
autonomous, or somewhere in between
• When learners are coerced, they self-regulate because of fear or shame
• When learners are helped to see the value of rules in a personally
meaningful context, they learn to self-regulate around external
controls that they have “integrated” into their value system
• Integrated self-regulation allows autonomous individuals to maintain
motivation, even in a controlling environment—IF the rules are in fact
meaningful to them! Learners need:
– Autonomy support
– Understanding that rules can have personal meaning
Self-regulation goes hand in hand with autonomy in
the world of self-determined physicians who are
independent, responsible, inquisitive and fulfilled
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Positive Factors
PERSONAL:
•Drive to excel
•Reflection
•Self assessment
•Goal setting &
tracking
•Work/life balance
Inherent or
Learned SD
traits
ENVIRONMENTAL:
•Healthy work climate
•Peer/social support
•Manageable schedule
Autonomy
Relatedness
Competence
Educationally
Enhanced
Self-
Determination
EDUCATIONAL:
•Practice of adult learning
•Learning from preceptors, peers
& patients
•Didactics & self-directed learning
•Learner input into learning
agenda
Self determined
physician:
independent
responsible
inquisitive
fulfilled
Negative Factors
PERSONAL BARRIERS:
•Conflicting priorities
•Weak professional
commitment
•Poor time management
•Lack of social support
•Sleep loss & burnout
SYSTEM BARRIERS:
•Abusive hours
•Paperwork burden
•Inflexible regulations
•Patient safety/litigation
protections
•Lack of continuity in
patient care
EDUCATIONAL BARRIERS:
•Passive learning
•Limited freedom of
choice
•Harsh evaluation; lack
of constructive feedback
•Insufficient time for
reflection & learning
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